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ORAL and oropharyngeal complications of intubations have been cited as some of the most common causes of complaints against anesthetists. Reviews of closed claims analyses have shown that dental injury accounts for approximately one third of all incidents reported. 1 In one prospective study, 745 patients were evaluated before and after anesthesia and were found to have dental trauma 12.1% of the time and an overall oral injury incidence of 18%. 2 In a similar study of 404 patients, an incidence of oral trauma of 6.9% was found. 3 Clearly, the literature places emphasis on damage limited to teeth. Less common complications include mucosal tears, dentoalveolar fractures, dislocation of the temporomandibular joint, and injury to the hypoglossal and lingual nerves. 4–7 Most often, mucosal tears are the result of trauma from the blade of the laryngoscope, the tip of the endotracheal tube, or the fiberoptic endoscope and heal without incident. Here, we report adverse sequelae to mucosal lacerations not yet found in the literature. In both cases, the patients developed osteomyelitis of the mandible after laceration of the overlying oral mucosa after a traumatic intubation.

Case Reports

Case 1

A 55-yr-old man presented with the chief complaint of pain and paresthesia to the right lower jaw. The patient reported that approximately 2 months before, he had undergone left thyroid lobectomy for treatment of papillary carcinoma of the thyroid under general anesthesia via
endotracheal tube. Review of hospital records confirmed such a procedure, and administration of anesthesia was noted to be routine, with use of a No. 3 Macintosh blade for direct laryngoscopy. The trachea was intubated on the first attempt without difficulty, and no mucosal lacerations were reported at the time of intubation. Immediately subsequent to the procedure, the patient noted an ulceration of the right posterior medial aspect of the mandible. After 1 month of persistent ulceration and new-onset lip numbness, the patient sought treatment.

Intraoral examination revealed a 1 × 1-cm exposed bony sequestrum on the right posterior lingual cortex of the mandible, with ulceration of the overlying mucosa. There was also hypoesthesia to a small region on the patient’s lower right lip. A computed tomography image was obtained and showed a linear lucency along the medial aspect of the body of the right mandible, with associated small defects in the lingual cortex at the level of the right second molar (fig. 1).

Fig. 1. Axial view of a computed tomographic scan with contrast showing a linear lucency along the medial aspect of the body of the right mandible with associated defect in the lingual cortex and the level of the first and second molars.

Fig. 1. Axial view of a computed tomographic scan with contrast showing a linear lucency along the medial aspect of the body of the right mandible with associated defect in the lingual cortex and the level of the first and second molars.

The patient underwent debridement and biopsy of the exposed bone in the operating room under general anesthesia. Results of the surgical pathology report revealed bone with marrow fibrosis and chronic inflammation consistent with osteomyelitis. Anaerobic and aerobic cultures of the soft tissue surrounding the lesion grew organisms commonly associated with osteomyelitis.

After review of antibiotic sensitivity reports and consultation with Infectious Disease, the course of therapy was decided to be 6 weeks of oral antibiotics. Although the patient’s hypoesthesia progressively resolved and the mucosal ulceration completely healed, the patient noted persistent pain at the 6-week mark. Repeated cultures showed organisms associated with osteomyelitis; therefore, the patient continued oral antibiotics for a total of 6 months. The final follow-up after the 6-month course of therapy revealed a well-healed surgical site, normal lip sensation, and a pain-free patient.

Case 2

A similar case involved a 54-yr-old woman who, after a tracheal intubation for dilation and curettage, noticed an ulceration along the right mandible. Again, the anesthesia was noted to be uneventful, with intubation of the trachea on first attempt with a No. 3 Macintosh blade. No trauma to the oral mucosa was documented. On presentation to our office, a fluctuant swelling was noted on the mandibular right posterior lingual cortex on examination. The lower right second bicuspid had slight tenderness with pressure. The examination results were otherwise unremarkable. A computed tomography image was obtained and revealed erosion of the right mandibular body (fig. 2). The patient was taken to the operating room for biopsy, and results revealed osteomyelitis. Based on culture and sensitivity reports, a combination of long-term intravenous and oral antibiotics was deemed necessary. After 3 months of therapy, the mucosal laceration had healed, and the patient was pain-free. Repeat radiographs at the six-month follow-up appointment revealed a well-healing biopsy site with adequate bony fill.

Fig. 2. Axial view of a computed tomographic scan with contrast showing a lytic radiolucency along the medial aspect of the body of the right mandible with erosion of the lingual cortex in the region of the second bicuspid and first molar.

Fig. 2. Axial view of a computed tomographic scan with contrast showing a lytic radiolucency along the medial aspect of the body of the right mandible with erosion of the lingual cortex in the region of the second bicuspid and first molar.

By strict definition, osteomyelitis
is inflammation of the medullary portion of the bone, but it often progresses to involve the cortical bone and periosteum. 8 Most cases of osteomyelitis of the jaws in developed countries can be attributed to extension of a dentoalveolar infection or are in association with traumatic fractures of the jaws. 9 Predisposing factors, such as chronic systemic disease, immunocompromise, and disorders that lead to hypovascularity of bone, have been implicated. In addition, social history findings of tobacco use, alcohol, or intravenous drug abuse have been associated with an increased risk of developing osteomyelitis. 8

Presentation is typically some combination of the usual signs of inflammation, including pain, swelling, trismus, erythema, and exudate. Fragments of nonviable bone called sequestrum
may be present and protrude throughout the overlying mucosa. Radiographically, the bone may appear normal in early osteomyelitis or may present as an irregular radiolucent area after 4–6 months of progression of the infection. 8,9

Diagnosis begins with clinical and radiologic findings. Adjunctive procedures include bone biopsies and cultures. Treatment varies depending on the extent of invasion and may range from intravenous or oral antibiotics alone to complete resection of the involved bone. Hyperbaric oxygen has been used in cases that are refractory to aggressive surgical and antibiotic intervention. 8,9 While cases of osteomyelitis usually resolve with treatment, the morbidity associated with the process is clear.

Summary

The majority of oral ulcerations from intubation may heal without incident; however, the potential to develop a serious complication such as osteomyelitis does exist. Identification of risk factors, including irradiated bone or immunosuppression, should yield increased care during direct laryngoscopy. Further, if a mucosal tear is sustained, recommendation for follow-up with an oral and maxillofacial surgeon should be provided such that intervention may be initiated early, if required.

Fig. 1. Axial view of a computed tomographic scan with contrast showing a linear lucency along the medial aspect of the body of the right mandible with associated defect in the lingual cortex and the level of the first and second molars.

Fig. 1. Axial view of a computed tomographic scan with contrast showing a linear lucency along the medial aspect of the body of the right mandible with associated defect in the lingual cortex and the level of the first and second molars.

Fig. 2. Axial view of a computed tomographic scan with contrast showing a lytic radiolucency along the medial aspect of the body of the right mandible with erosion of the lingual cortex in the region of the second bicuspid and first molar.

Fig. 2. Axial view of a computed tomographic scan with contrast showing a lytic radiolucency along the medial aspect of the body of the right mandible with erosion of the lingual cortex in the region of the second bicuspid and first molar.